GRAND RIVER HEALTH CARE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
treated residents in a manner to maintain their dignity when they did not pull privacy
curtains and left residents exposed to their roommates or families and staff walking by
the resident’s room, which affected three of 13 sampled residents (Resident #11, #33, and
#41). The facility census was 41.
Review of the facility’s undated resident rights policy showed:
– Each resident shall be treated with consideration, respect a full recognition of his/her
dignity and individuality, including privacy in treatment and care of his/her personal
needs.
1. Review of Resident #41’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 6/28/18, showed:
– Severe cognitive impairment;
– Always incontinent of bowel and bladder;
– Required extensive assistance of staff for all activities of daily living (ADLs).
Review of the resident’s care plan, updated on 6/13/18, showed:
– Total dependence with ADLs due to decreased cognitive ability: Ensure the resident is
clean, dry, and appropriately dressed at all times;
– Skin breakdown related to bowel and bladder incontinence and mobility issues: Staff will
provide perineal care as needed.
Observation on 7/9/18, at 4:10 P.M., showed Certified Nurse Aide (CNA) A and Nurse
Assistant (NA) A did the following:
– Entered the resident’s room to perform perineal care;
– Shut the room door, did not pull the privacy curtain between the residents, and pulled
back the resident’s bedding while the resident’s roommate lay in the bed beside him/her;
– Pulled down the resident’s trousers and opened up the resident’s brief;
– Exposed the resident’s perineal area to check for wetness;
– Staff discussed if the resident was wet enough to provide perineal care and then
redressed the resident.
2. Review of Resident #33’s admission MDS, dated [DATE], showed:
– Severe cognitive impairment;
– Always incontinent of bladder;
– An [MEDICAL CONDITION] (loop of small intestine connected to the abdominal wall to
create a stoma, to pass stool out of the body);
– Total dependence of staff for all ADLs.
Review of the resident’s care plan, updated on 6/26/18, showed:
– Problem: Urinary incontinence;
– Approach: provide good peri-care after each incontinent episode and staff to change
[MEDICAL CONDITION] as needed to prevent breakdown.
Observation on 7/9/18, at 4:25 P.M., showed CNA A and NA A did the following:
– Entered the resident’s room to perform perineal care and pulled back the resident’s
bedding:
– Staff exposed the resident’s abdomen, opened a soiled brief, and started perineal care;
– During perineal care staff ran out of gloves, NA A left the resident’s room and left the
door wide open;
– The resident lay on his/her back with his/her genitals and [MEDICAL CONDITION] bag
exposed to residents and staff walking by the resident’s room;

Based on interview and record review, the facility failed to ensure they provided
residents or residents’ with a Skilled Nursing Facility (SNF) Beneficiary Protection

Based on observation and interview, the facility failed to maintain a safe and clean
environment for the residents. The bathroom floors and thresholds in resident rooms # 102,
#104, #105, and #106 were stained black and sticky. This affected eight residents. The
facility sidewalk had a crumbling area the width of the walk. This could affect any
resident or staff using the sidewalk. The facility census was 41.
Observation on the entrance to the survey on 7/9/18 showed the sidewalk on the west side
of the facility had an area one foot long and across the width of the sidewalk that was
crumbling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interviews, the facility failed to assure they
provided care and treatment in accordance with professional standards of practice when
staff failed to follow physicians’ orders for two residents (Resident #11 and #13) of 13
sampled residents. The facility census was 41.
Review of the facility’s policy for Physician Orders, (MONTH) (YEAR), showed:
-All medication and treatment regimes will be ordered by a licensed physician authorized
to practice medicine in this state and must be seen by the physician at least every sixty
days;
-Treatment orders specify what is to be done, location and frequency,and duration of the
treatment.
1. Review of Resident #11’s quarterly Minimum Data Set (MDS), a federally mandated
assessment to be completed by the facility, dated 5/4/18, showed:
– Severe cognitive impairment resident is rarely/never understood;
– Extensive assist of two staff for bed mobility, transfers, dressing and hygiene needs;
– The resident has a feeding tube;
– Indwelling catheter and always incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised on 6/18/18, showed:
– Total dependence on staff for care due to decreased cognitive ability and a [DIAGNOSES
REDACTED].
– Impaired skin integrity related to a feeding tube with stated goal that resident will
not have further advancement of current gastric burn;
– Wound care and dressing changes per physicians’ orders;
– Change incontinent pads as soon as possible after the resident voids or defecates.
Review of the resident’s physician’s orders [REDACTED].
– An order date 7/2/18 for triple antibiotic ointment to gastric burn under left breast,
cleanse area with warm water until healed.
– A new order dated 7/5/18, to cleanse gastric burn under left breast with warm water,
apply thin layer of hydrogel (a gel that assists in protecting the body from wound
infection and promotes efficient healing), and cover with ABD (abdominal gauze pads) pad

– When a dressing change order is needed, staff should notify the physician and obtain the
new order; this should be documented;
– Nursing staff does not have the authority to change a dressing order.
– The nurse on the 6:00 P.M. to 6:00 A.M. shift should have completed the treatment to the
resident’s gastric burn as it was ordered by the physician to be done twice daily.
– If the dressing needed to be changed, she expected nursing staff to apply a dressing
and the area should be covered at all times;
-The facility no longer utilizes a restorative aide and if the physician ordered hands
splints then she expects staff to follow physicians orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure staff
performed proper, complete perineal care (cleansing of the perineal and rectal areas) to
three incontinent, dependent residents of 13 sampled residents (Resident #11, #13 and
#33). The facility census was 41.
Review of the facility’s policy on perineal care, Nursing Guidelines Manual, (MONTH)
(YEAR), showed:
– Purpose: To cleanse the perineum and to prevent infection and odor;
– Guidelines: Separate the legs and flex the knees, use one gloved hand to stabilize and
open the perineal folds, with the other hand, wash from front to back;
– Roll the resident away from you, use a new washcloth and wash around the rectal area,
rinse and dry, remove gloves, and wash hands.
1. Review of Resident #33’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/30/18, showed:
– Severe cognitive impairment, always incontinent of bladder, and [MEDICAL CONDITION]
(loop of small intestine connected to the abdominal wall to create a stoma, to pass stool
out of the body);
– Total dependence of staff for all activities of daily living (ADLs).
Review of the resident’s care plan, updated on 6/26/18, showed:
– Problem: urinary incontinence;
– Approach: provide good peri-care after each incontinent episode and staff to change
[MEDICAL CONDITION] as needed to prevent breakdown.
Observation on 7/9/18, at 4:25 P.M., showed:
– Certified Nurse Aide (CNA) A and Nurse Assistant (NA) A entered the resident’s room to
perform perineal care, washed and gloved their hands, and pulled back the resident’s
bedding.
– CNA A removed the resident’s [MEDICAL CONDITION] bag, emptied it and placed it back on
the resident;
– Opened the resident’s brief, wet with urine, and CNA A rolled the resident on his/her
right side;
– NA A wiped the resident’s left buttock, did not wipe the right buttock, thighs, or all
areas wet with urine;
– Rolled the resident onto his/her back, and CNA A wiped down and back up the inner
perineal fold twice, wiped each groin area once, and did not wash all frontal areas wet
with urine.
During an interview on 7/9/18, at 5:00 P.M., NA A said he/she should have cleaned the
sides of the legs, inner perineal areas, and all areas wet with urine during perineal
care.
During an interview on 7/9/18, at 5:10 P.M., CNA A said:
– He/she should not wipe down the inner perineal folds and back up again;
– During perineal care, all areas soiled should be cleaned.
2. Review of Resident #11’s quarterly Minimum Data Set (MDS), a federally mandated
assessment to be completed by the facility, dated 5/4/18, showed:
– Severe cognitive impairment; resident is rarely/never understood;
– Extensive assist of two staff for bed mobility, transfers, dressing and hygiene needs;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to assure staff
used proper techniques and follow facility policy to reduce the possibility of accidents
and injuries during mechanical lift transfers. This affected two of 13 sampled residents
(Resident #11 and #33). The facility census was 41.
Review of the facility’s policy on Hydraulic Lifts, Nursing Guidelines Manual, (MONTH)
(YEAR), showed:
– Open the lift legs to the widest point, at the closest location to the resident (bed or
chair);
– Position the sling under the resident and move the lift with the base under the bed;
– Attach the S hooks to the overhead bar and raise the resident, when the resident has
been lifted clear of the bed, grasp the bar, and move to the chair;
– Position the wheelchair and lock the wheelchair brakes.
Review of the manufacturer’s instructions on the battery operated mechanical lift, dated
2011, showed:
– Transferring the resident: Wheelchair wheel locks MUST be in a locked position before
lowering the resident into the wheelchair for transport.
1. Review of Resident #33’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/30/18, showed:
– [DIAGNOSES REDACTED].
– Severe cognitive impairment and did not ambulate;
– Total dependence of staff for all activities of daily living (ADLs).
Review of the resident’s care plan, updated on 6/26/18, showed:
– [DIAGNOSES REDACTED].
– ADL function: Resident is unable to transfer self-related to cognitive decline and left
femur fracture: Resident will transfer with assist with use of mechanical lift, instruct
staff in use of mechanical lift for transfers and proper transfer techniques, and provide
two assistance for transferring.
– Total dependence of staff for all ADLs.
Observation on 7/9/18, at 4:25 P.M., showed:
– Certified Nurse Aide (CNA) A and Nurse Assistant (NA) A completed perineal care and
prepared to transfer the resident to his/her wheelchair;
– Staff rolled the resident, placed a lift sling under the resident, and attached the
sling loops to the lift bar;
– NA A raised the resident off the bed, pulled the lift away from the bed, and moved the
lift toward the resident’s wheelchair;

Based on interview and record review, the facility failed to use the services of a
registered nurse (RN) for at least eight consecutive hours a day, seven days a week, for
resident care. The facility census was 41.
The facility did not provide a policy for staffing.
Review of the staff schedule for (MONTH) (YEAR), showed no RN coverage scheduled for the
weekends.
During an interview on 7/12/18, at 12:00 P.M., the Administrator said:
– He knew that it is a federal requirement to have RN coverage daily;
– The Director of Nursing (DON) acts as the RN coverage Monday thru Friday;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
administered medications with a medication error rate of less than 5%. Facility staff made
four medication errors out of 28 opportunities for error, resulting in a medication error
rate of 14%. This affected two of 13 sampled residents (Residents #21 and #29). The
facility census was 41.
Review of the facility’s policy on Medication Administration Guidelines dated (MONTH)
(YEAR), showed it is the purpose of this facility that residents receive their medications
on a timely basis and in accordance with established policies;
– To benefit a resident’s health as ordered by the physician;
– Staff are directed to read the label three times before administering the medication;
– Guidelines: The person administering the drugs must chart medications immediately
following the administration; to include the date, time administered, dosage, etc.; must
be entered in the medical record; and signed by the person entering the data;
– A current Physician’s Desk Reference (PDR) or drug reference is available at each
nurses’ station.
Review of the online undated Physician Digital Reference showed:
– Potassium (for the treatment of [REDACTED].
1. Review of Resident #29’s (MONTH) physician’s orders [REDACTED].
– [MEDICATION NAME] 15 milligrams (mg), take one tablet orally once daily for pain;
– [MEDICATION NAME] 25 mg, take one tablet orally every morning;
– Potassium chloride (CL) ER (extended release), 10 milliequivalents (meq), take one
tablet orally once daily for supplement.
Observation on 7/12/18, at 8:40 A.M., showed:
– Certified Medication Technician (CMT) A prepared the resident’s morning medications in
the hall outside the resident’s room;
– Obtained the resident’s card of [MEDICATION NAME] 15 mg and popped the medication into
the medication cup, (the card read to take with food);
– Obtained the resident’s card of spiralactone 25 mg and popped the medication into the
medication cup, (the card read to take with food);
– Obtained the resident’s card of potassium 10 meq and popped the medication into the
medication cup, (the card read to take with food);
– Entered the resident’s room and administered the cup of medications to the resident;
– CMT A left the resident’s room and did not provide a snack for the resident.
During an interview on 7/12/18, at 8:45 A.M. the resident said:
-He/she had an upset stomach today and did not eat breakfast today;
-He/she frequently does not eat breakfast.
2. Review of Resident # 21’s (MONTH) POS showed the following:
-[MEDICATION NAME] 15 mg, take one tablet orally once daily for pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
dated a multi-dose bottle when opened, failed to ensure several residents’ insulin pens
and other medications remained in a refrigerator when facility staff defrosted the
refrigerator located in the medication room for two of 13 sampled residents (Resident #20
and #33) and failed to ensure staff did not store their food with residents’ medications.
The facility census was 41.
Review of the facility policy, dated (MONTH) (YEAR), titled Storage of Medications,
showed:
– Biologicals or medications requiring refrigeration must be kept in a separate, securely
fastened refrigerator at or near the nurses’ station or in a refrigerator within a locked
medication room;
– Drugs must be stored at appropriate temperature levels; drugs requiring refrigeration
must be stored between 36 and 46 degrees Fahrenheit (F);
– No discontinued outdated or deteriorated drugs or biologicals may be retained for use.
– All controlled substances must be stored under double lock and key;
-When drugs are stored in the same refrigerator as foods, the drugs must be kept in a
closed container clearly labeled DRUGS.
Review of the facility undated policy titled Food Safety Requirements showed:
– Food items not fully consumed or food items intended for later resident consumption,

Based on observation, interview and record review, the facility failed to ensure dietary
staff served food at an appetizing temperature. This had the potential to affect all
residents. The facility census was 41.
Observation on 7/10/18, at 7:25 A.M., showed Cook A began serving the residents. He/she
took the lids off the steam table. At 7:48 A.M., staff served the last tray as a test
tray. The pancakes were 96.6 degrees Fahrenheit (F). The sausage was 111.4 degrees F. The
scrambled eggs were 114.6 degree F. The milk’s temperature was 44.4 degrees F.
During an interview on 7/12/18, at 9:05 A.M., Cook A said the food needs to be 145 degrees
F when served.
During an interview on 7/12/18, at 9:15 A.M., the dietary manager said hot food should be
served at 135 degrees F and cold food should be served at 42 degrees F.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
followed infection control protocols to prevent the spread of infection when staff did not
wash their hands when entering resident rooms or before giving care, when going from a
soiled area to a clean area during perineal care, before touching clean items and
medications, which affected three of 13 sampled residents (Resident #11, #13 and #33).
Additionally, staff poured medication from a med cup back into the medication bottle,
which affected one additional resident (Resident #21). The facility census was 41.
Review of the facility’s policy on Gloves, Nursing Guidelines Manual, (MONTH) (YEAR),
showed:
– Wear gloves when it can be reasonably anticipated that hands will be in contact with
mucous membranes, non-intact skin, any moist body substances (blood, urine, fecal
material, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with
these substances) and/or persons with a rash.
– Gloves must be changed between residents and between contact with different body sites
of the same resident.
– Remember: Gloves are not a cure-all. They should reduce the likelihood of contaminating
the hands, but gloves cannot prevent penetrating injuries due to needles or sharp objects.

– Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of